Employee Benefits Planning Assn. Meredith Mathews, MD MPH

Transcription

1 Employee Benefits Planning Assn. Meredith Mathews, MD MPH 1

2 Meredith Mathews, MD, MPH Chief Medical Officer 18 years in practice of nephrology; CMO & SVP for Health Services, Premera Blue Cross; CMO & SVP for Health Services, Medica; Interim President, Allina Medical Clinics 50 clinics & 500 physicians; CMO, LifeMasters Supported Self Care DM company with 600K members; 10 years as surveyor, instructor & ROC member, NCQA 2

3 Key Trends in DM 3

4 Six Trends in Disease Management a review of articles over the last 90 days. 1. The prevalence of chronic illness continues to increase as has its impact 2. DM companies have moved from single condition specialists to management of the whole population through the integration of analytic tools for assessing risk and for population segmentation 3. Health Management is increasingly being seen as "strategic imperative for health plans.. Leading them to take it back inside 4. Integrated delivery model.. Providers find ways to participate 5. Changes in the nurse coaching model: from managing "compliance" to patient centered behavioral change for the purpose of self management 6. Government as driver of health care change - though MHS has been discontinued, other evaluations of chronic care models continue 4

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6 DM companies have moved from single condition specialists to management of the whole population through the integration of analytic tools for assessing risk and for population segmentation.. 6

7 Key Changes In DM Deepen disease management - Medication management Healthways partnership with Medco a PBM LifeMasters and others bridge the medical mental health gap Integrated evaluation methods for whole population management Evaluation Methods Health risk assessment Predictive modeling Population segmentation (stratification) Whole population health.coverage of the full continuum from wellness, risk factor management, chronic disease, complex case management Wellness and risk factor management Metabolic syndrome Expansion outside of traditional DM Partnerships with community organizations for wellness activities Healthways acquires an alternative care network 7

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10 Health Management is increasingly being seen as "strategic imperative for health plans.. Leading them to take DM back (they have learned from the DM companies how to do it!) Aetna: Active Health United Health Care: Optum Anthem/Wellpoint 10

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12 Integrated delivery model.. Providers find ways to participate. Chronic Care Model Medical Home 12

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14 Changes in the nurse coaching model: from managing "compliance" to patient centered behavioral change for the purpose of self management 14

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16 Government as driver of health care change: Although the MHS program has been discontinued, other evaluations of chronic care models continue.. MHS Programs - CMS cancels the only randomized controlled trials Demonstrations High cost care demo Medical Home demo Special Needs Plans 16

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19 Sorting through the "trends" deconstructing the program to identify evidence based practices 19

20 Overview Statement - look for an evidence basis for the "what" and the "how" Tactics used by most programs Provider education Provider feedback Provider reminders Patient education Patient reminders Patient financial incentives Case management multidisciplinary teams Collaborative Decision Making 20

21 Results of studies. Study Results: provider education, feedback and reminders enhance provider adherence to guidelines resulting in improvements in patient disease control medication therapy management - regular reviews of medications can result in reduced hospitalizations patient education, reminders and financial incentives were associated with improvements in patient disease control Summary and translation: most interventions are strongest at improvements in process measures Impact on avoidable hospitalizations: influenza vaccine, medication therapy management 21

22 Other variables which influence population based impact Percent of people in the program (at least 40%) Frequency of contact with the nurse: total nursing time Duration of participation months 22

23 Operating Models drive both the cost and the likelihood of effectiveness. Operating Models web based telephonic face to face DM scope of services Wellness care Chronic care coaching Complex case management 23

24 Evidence of DM in action 24

25 Traditional patient education methods are not as effective when carefully evaluated Information Giving Simple Knowledge Transfer CDC (Type II DM) only 18 of 54 studies show positive effect on glycemic control Norris 72 studies reviewing info only vs. collaboration less effective glycemic control, weight change and lipid control Kaiser 12 randomized controlled trials no effect of info only on hospital rates, doctor visits, asthma attacks and appropriate medication use 25

26 To determine if participation in patient empowerment program increases self efficacy and decreases blood glucose Anderson et al Diabetes Care 18: Method: Randomized controlled trial - 6 sessions over 6 weeks restudy at 12 weeks relatively well educated Results: Intervention group had: Increased self efficacy Lower HbA1c p<.05 26

27 Reduction of Lower Extremity Clinical Abnormalities in Patients with Diabetes Littleman et al Annals Int Med 119: Method: N=352, General Internal Med Clinic 12 month intervention, Study intention: decrease the number of amputations (by building confidence in self management) Results: Intervention patients More likely to be observing appropriate foot care behaviors 68% vs 28% in controls Fewer foot lesions odds ratio.41 compared to controls p<.05 27

28 Other Conditions Lorig et al Medical Care 37: Multiple Complex Co morbidities: heart disease, lung disease, stroke, and arthritis Peer to peer based program to build self efficacy and self management Results: Decreased hospitalizations in the treatment group and when hospitalized an average stay of one day less than controls 28

29 Effect of Collaborative Decision Making on Engagement Shared or collaborative decision making is a process where the patient and the clinician consider available information on treatment options, consequences and consider how these fit with the patient s preferences not just the what but the how Currently, medical practice rarely employs collaborative decision-making; in a study of 1000 physician visits, the patient did not participate in decisions 91% of the time Collaboration is more likely to result in a plan the patient understands, has confidence in and is more likely to prolong engagement Greenfield and colleagues, Treatment group patients were provided with a 20-minute intervention designed to increase their participation in decision making and information seeking with the provider (37) The control groups received purely didactic information Study patients showed significant decreases in HbA1c values from baseline Controls no changes There were no differences in diabetes knowledge between the two groups 29

30 Examples from DaVita VillageHealth (ESRD) Achieved 5% Lower Cost (vs control) in NY Demo 13% Reduction In Hospital Admissions Over 4 Years for BCBS Client Medical Cost Per Member Per Month $3,000 $2,500 $2,000 $1,500 $1,000 2, % Below 2,395 Hospital Admissions Per 1,000 Members 1,800 1,600 1,400 1,200 1, $ $0 VH Group Control Group 0 '01 '02 '03 '04 '05 Before VillageHealth program introduced With VillageHealth program 30

31 Questions for future What role with consumer directed health care play? Are behavioral risk factors next? How will the evolution of biometric monitoring and personal health records influence the development of the field? How will advancements in traditional medicine be used to improve either detection or treatment? There is now a blood test for Metabolic Syndrome Are there any more markets to tap? Nursing homes Long term care insurance Will employers frame their benefits to take advantage of the "best models What role will increasing transparency play? With help of govt evaluators the questions have evolved From Does it work? To what aspects of the program work? How much does each component contribute? Are certain segments more likely to benefit than others? 31

32 The Holy Grail: Changing behavior to prevent disease Interactive Data Systems Chronic Clinical Risk Factors CHF Current Behavioral Risk Factors Our Future All of the above plus more real time two way remote interaction between pts., disease managers, and MDs (e.g. interactive TV, implantable devices, PDAs, cell phones, other wireless technologies) 32 Copyright LifeMasters Supported SelfCare Inc All Rights Reserved.

33 New Technology 33

34 Will employers play a role in shaping the future? 34

35 New Venues for DM 35

36 Transparency - New players looking under the hood 36

37 Conclusions Be clear about what you need Understand the likelihood of the program strategy and operating model delivering that.. Don't buy more than you need 37